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Exploring Health Reform and Criminal Justice: Rethinking the Connection between Jails and Community Health
ISSUE PAPER
January 2011
The Intersection of Public Health and Public Safety in U.S. Jails: Implications and Opportunities of Federal Health Care Reform Bonita M. Veysey, School of Criminal Justice, Rutgers-The State University of New Jersey
Perspective
mental and substance use disorders among detainees and inmates, the paper discusses common strategies for
This paper was written from the perspective and experi-
the organization and delivery of health care within jails
ence of the Corrections and Re-entry Policy Research
together with current financing strategies. The paper
Center at Rutgers-Newark1
concludes with a discussion of the possible impacts of
at the Rutgers School of
Criminal Justice. The Center focuses on community and
health care reform on jail services.
institutional corrections policies and practices and on the difficult transitions between arrest and eventual release.
Introduction
The Center investigates questions related to legislative and policy initiatives, operations and procedural impacts,
The United States has achieved an historic milestone.
organizational change and community and individual
A 2009 report by the Pew Center on the States4
outcomes. As an organization embedded in Rutgers-
estimates that 1 in 99 Americans are incarcerated in our
Newark, the Center has a strong commitment to urban
nation’s jails and prisons – more than 2.3 million adults
issues, particularly those that affect Newark and northern
behind bars on any given day. On a yearly basis, the numbers
New Jersey. In this regard, the health of New Jersey’s jail
are staggering. Local jails, for example, process nearly 13
detainees and inmates has particular salience to general
million admissions a year.5
public health. New Jersey has the highest incarceration rate of any state of persons on drug-related charges.2
Jail detainees and inmates are not representative of
Consequently, rates of other health problems, such as
the U.S. population. They are disproportionately young,
tuberculosis, sexually transmitted diseases, hepatitis C
male, persons of color and poor.6, 7 They also have high
3
and HIV/AIDS are very high. Poverty is highly concentrated
rates of health problems (such as injuries, chronic conditions
in New Jersey’s urban centers.
Health care reform,
and infectious diseases), acute and chronic psychiatric
particularly as applied to the jail population, is of deep
disorders and alcohol and other drug addictions.8, 9 Upon
interest to New Jersey’s state and county governments.
booking, in fact, arrestees are often at their sickest.
This paper discusses the implications and opportunities
Jails are required to provide treatment for acute medical
of health care reform for jails from a public health
and psychiatric problems10 and often focus their
perspective, beginning with an overview of U.S. jails and
resources on urgent care and crisis stabilization.11
the characteristics of the jail detainee and inmate
this reason, jails are an attractive treatment option for
For
population. Prevalence estimates of acute, infectious and
police and judges. With few affordable treatment services
chronic diseases, mental and substance use disorders and
in the community, it is not unknown for police officers to
experiences of interpersonal violence follow. In view of
arrest and judges to remand people to jail with the clear
the nature of U.S. jails and the high rates of medical and
knowledge that they will receive treatment that they may not receive (or may refuse) if left in the community.12 The intersection of poverty, poor health and justice involvement is not accidental. The three factors go hand in hand. Poor people are more likely than their more affluent counterparts to be arrested; they are less likely to have health insurance of any kind, including Medicaid, and to have received regular health care; and they have
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ISSUE PAPER high rates of mental health and substance use disorders and consequently other medical concerns.
access to medication could have a substantial effect on continuity of care from pre-arrest to detention to re-entry while
In many ways, poverty is at the center of the need for correctional facility-based health care.
reducing
recidivism
and
increasing
overall
public safety.
First, a large
proportion of individuals arrive at the jail in acute
Because of the local nature of jails and the characteristics
psychiatric crisis and/or with active addictions. These
of those held in their custody, jails are in a unique position
same individuals often have not received treatment in the
to serve as public health outposts by embracing a public
community. In some cases, this is because the person
health model. Five principles derived from the Hampden
refuses or does not pursue treatment, but in many other
County (Mass.) Correctional Center community-oriented
cases community treatment resources are simply non-
model can guide this work, including “(1) early assessment,
existent and the person lacks insurance coverage to pay
(2) prompt and effective treatment at a community
for the few services that may be available. Some argue,
standard of care, (3) comprehensive health education,
in fact, that lack of access to medical, mental health and
(4) prevention measures and (5) continuity of care in the
substance abuse treatment contributes to arrest and
community upon release.”16 Sound clinical practice based
recidivism.13 Second, persons without financial resources
upon principles of public health has been found to
often cannot make bail and therefore remain in jail
increase both public health and public safety. Providing
awaiting trial and sentencing.
In many cases, these
effective treatment at a high standard of care together
individuals present no greater risk to the community than
with improving the health literacy and good health
those who are released either through bail or on their
behaviors
own recognizance. Jails are responsible for providing
been demonstrated to increase self-efficacy and reduce
of
detainee
and
inmate
patients
has
health care – including treatment of acute and chronic
risk behaviors, leading to a reduction in recidivism.17
medical and psychiatric disorders and detox from drugs
Ultimately, these factors can reduce crimes (particularly
and/or alcohol – for detainees for as long as they are in jail.
those that are drug-related), infection rates in the community, use of urgent and emergency care and
The Patient Protection and Affordable Care Act (ACA)
community costs.
promises to expand health coverage to all U.S. citizens.14
related to improved person-level outcomes, including
Increased continuity of care is
This legislation may reduce the number of arrests by
improved health and well-being and longer periods of
providing treatment for people in the community who
time in the community.18
have mental health and substance use disorders and improve the health of those held in jail (assuming that
Overview of U.S. Jails
future arrestees will have had preventive care and regular treatment for medical needs prior to arrest).
Jails are short-term facilities that hold people who are
Further, the ACA may allow for unsentenced jail
awaiting trial and those serving short sentences, generally
detainees to maintain their health insurance benefits,
of one year or less.19
Many people booked into jail are
This may reduce pressure on jail
released pending trial and their time in jail is very brief,
health care staff to provide minimal services and to use
ranging from several hours to a few days. Sixty-four
cheaper, less effective alternatives in order to contain
percent of the population turns over every week.20 The
costs, thus encouraging local correctional professionals
average stay in jail for a sentenced inmate is about three
to provide high-quality treatment at a community
months (92 days).21 As such, jails are best characterized
standard of care. Additionally, greater use of electronic
as people-processing institutions. At mid-2009, 767,992
medical record systems could increase information
individuals were confined in the nation’s nearly 3,000
transfer across a range of providers and expand access
jails.22 However, this number does not capture the vast
to pharmaceuticals to reduce symptoms and increase
number of persons processed through these facilities.
health. Thus, increased coverage, information transfer and
Local jails admitted an estimated 12.8 million people
15
including Medicaid.
Veysey
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ISSUE PAPER during the 12-month period from July 1, 2008, and
Regardless of size, all jails, as 24-hour secure facilities, are
June 30, 2009.23 Because some individuals are booked
under constitutional mandate to provide adequate care
into
nearly
so that those held in custody do not suffer beyond what
13 million admissions represent approximately 9 million
is allowable by law. In addition to providing adequate
jail
more
than
once
a
year,
these
24
unique individuals.
housing, clothing and food, custodial facilities have both the duty to protect individuals from harm and the duty
The country’s jail population has grown substantially over
to treat serious medical and psychiatric conditions.35, 36
the past decade. This trend is driven in large part by an
Case law, such as Estelle vs. Gamble37 and Bowring vs.
increase in detainees held pre-trial and in individuals
Godwin,38 established the right to receive medical and
returned to jail because of a probation or parole violation.
mental health treatment.39
Provision of medical and
Specifically, half the jail population on any given day
psychiatric services to persons in need is not optional.
is confined for a probation or parole violation or for bond
However, resources for meeting this mandate vary widely
forfeiture,25 while 62 percent of jail detainees have not
among jails and in direct relation to their size.
been sentenced.26 Further, the proportion of unconvicted jail detainees has grown 56 percent since 2000.27
Jail Demographics
Importantly, only approximately 4 percent of jail admissions This suggests that the vast
Jail detainees and inmates are largely young, poor, male
majority of jail detainees and inmates will return to the
and people of color. Currently, 88 percent of the jail
community — and in a relatively short time.
population is male. Although the largest proportion of
result in prison time.28
detainees and inmates are white, 43 percent of other Despite the growth in the jail population, arrests, particularly for violent crimes, have decreased.
29
races and ethnicities are overrepresented in comparison
Currently,
to the general population. Specifically, 39 percent are
approximately 22 percent of detainees and inmates are
black/African-American, 16 percent are Hispanic/Latino
held on violent charges, while 27 percent are held on
and 2 percent are Native American, Alaska Native, Asian,
property crimes, 30 percent on drug-related charges and
Pacific Islander and mixed-race/ethnicity.40 In 2002, 30
These
percent of the jail population was 24 or younger.41 However,
numbers are based on the total jail population on a given
according to the Federal Bureau of Investigation’s
day and do not represent the arrest charges of those
Uniform Crime Reports, 44 percent of all arrestees in
booked into jail over the course of a year. Those who are
2008 were 24 or younger.42
30
20 percent on public disorder or other crimes.
remanded and/or sentenced tend to have more serious charges than those who are released.
Based upon
People in jail are often poor and have few resources —
with
such as education, previous work experience, vocational
misdemeanor offenses and only a small number are
training and social networks — that could help them
charged with felonies.31, 32
secure a permanent living wage.
admissions,
the
vast
majority
are
charged
Compared to the
general population, persons in jail have low educational Jails are commonly operated by county or municipal
attainment.
governments. In some states (such as Alaska, Connecticut,
school education or less, 14 percent have a general
Specifically, 47 percent have some high
Delaware, District of Columbia, Hawaii, Rhode Island and
education diploma, 26 percent have a high school
Vermont), jails and prisons are integrated into a single
diploma and only 14 percent have any post-secondary
system. Jails vary in size from a few cells to a rated
education. In the general population, 33 percent have a
capacity of over 22,000 (Los Angeles County, Calif.). The
high school diploma and 48 percent have at least some
nation’s 171 jails with a rated capacity of 1,000 or more
post-secondary education.43 Further, nearly 40 percent
account for 42 percent of the jail population,33 but about
of jails do not offer any education programs.44
34
40 percent of jails hold 50 or fewer people.
Veysey
Sixty
percent of people in jail have never been married.45
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ISSUE PAPER Although 71 percent of respondents stated they had been
indigent care in the community, including serious and
employed in the month prior to their arrest, including full-
acute medical crises and comorbidity of multiple health
time, part-time and occasional work, 59 percent earned
and behavioral health problems.60 For example, women
less than $1,000 per month, including 19 percent who
are a small minority of jail populations. However, women
46
Six percent reported
in jail are more likely than their male counterparts to have
receiving income from welfare benefits and 9 percent
histories of physical and/or sexual abuse, mental illnesses,
received support from Social Security, Supplemental
drug addictions, and a wide range of medical problems
Security Income/Social Security Disability Insurance
(see specifics presented below). While representing only
(SSI/SSDI),
unemployment
a small proportion of the jail population, women use a
insurance or other compensation sources.47, 48 Only 10
disproportionate amount of correctional health services.61
reported no income at all.
worker’s
compensation,
percent have health insurance.49 General health studies of the U.S. population have found Health Status of Jail Detainees and Inmates
that rates of illnesses differ by gender and race.62 The intersection of health status, criminal behavior, sex, race
People generally are booked into jails directly from
and ethnicity and poverty is unknown. Although some
the community. When they arrive, they are often at
jail-based health-related studies report findings broken
their worst. Some arrive with injuries, others are drunk
down by sex, few do so by any of these other
or high and will detox during their stay in jail and others
characteristics. The information on health, mental health
suffer from acute mental illness. In addition, many jail
and substance use disorders discussed below will
admissions suffer from chronic health conditions and
describe sex differences in cases where information exists.
poor oral health.50 One study reported that 80 percent of jail detainees and inmates with chronic health problems,
Health disparities by race and ethnicity are assumed to
such as diabetes, heart conditions, hypertension and
be equal or greater in jail populations than the disparities
asthma, did not receive any regular medical care prior to
found in the general population. Summarizing the literature,
entering jail.51 Ninety percent have no health insurance52
Conklin and colleagues63 state that African-Americans
and over half used their local emergency room to receive
have higher death rates for heart disease, stroke, lung
needed care.53
cancer, breast cancer, motor vehicle accidents and homicide than white, non-Latino citizens. African Amer-
Racial and Sex Disparities
icans and Latinos also have higher rates of tuberculosis,
It is well documented that jail detainees and inmates are not representative of the U.S. population.
syphilis and AIDS.
While
approximately equal in society at large, men far exceed
Injuries and Acute and Chronic Health Conditions
women in jails, and the numbers of African Americans and
Serious injuries and acute health problems can decimate
Latinos in jail are disproportionate to their representation
a jail’s health care budget, especially if the jail is a small
in the general population.54
one.
Poor people are also
A single inpatient surgical procedure can cost
more likely to be found in jail than their more affluent
hundreds of thousands of dollars, severely limiting a jail’s
counterparts.55
capacity to provide care to other inmates.
Not only are there racial and sex disparities between
Very little information is available on injuries sustained
the jail and the general populations, there are racial and
prior to, or during, arrest and booking. In many cases,
sex disparities in health status,56 health literacy57, 58 and
jails maintain the right to refuse admission if the individual
services receipt59 within the general public. These disparities
has serious injuries, requiring the police to transport the
are compounded by the disproportionate representation
arrestee to an emergency room. However, 13 percent of
of specific population groups in jails, creating health care
jail detainees/inmates report being injured at some point
delivery challenges for jails similar to those of providing
after their admission to the jail.64
Veysey
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ISSUE PAPER In 2002, 53 percent of women and 35 percent of men in
percent. Less than 1 percent (0.6%) tested positive for
jails reported having a current medical problem.65
syphilis.72 In San Francisco, 27 percent of inmates tested
The
most commonly reported medical problems of individuals
positive for latent tuberculosis infection.73
in jails were arthritis (12.9 percent overall; 12.0 percent
tested in three large urban jails, rates of Chlamydia
Of women
male versus 19.4 percent female), hypertension (11.2
ranged from 15 percent to 22 percent, depending on
percent overall; 10.8 percent male versus 14.1 percent
jurisdiction, and rates of gonorrhea ranged from 8
female), asthma (9.9 percent overall; 8.7 percent male
percent to 9 percent.74
versus 19.4 percent female) and heart disease (5.9 percent overall; 5.5 percent male versus 9.2 percent
More importantly, the proportion of the correctional
female). Four percent noted kidney problems (3.0
(combined jail and prison) population to the total U.S.
percent male versus 8.9 percent female) and 3 percent
infected population for various diseases is dramatic.
reported having diabetes (2.5 percent male versus 4.1
Persons released from correctional settings represent 17
percent female).66 All of these chronic conditions except
percent of the total AIDS population, 13 percent to 19
arthritis require ongoing routine care, are very costly if
percent of those with HIV, 12 percent to 16 percent of
left untreated and may be improved by increasing patient
those with hepatitis B, 29 percent to 32 percent of those
education and health behaviors.
with hepatitis C and 35 percent of those with tuberculosis.75
Approximately 5 percent of women were pregnant at
According to the National Commission on Correctional
67, 68
Health Care,76 12 percent to 35 percent of the general
time of arrest.
population with communicable diseases spent time in jail Infectious Diseases
or prison in 1996.
Infectious diseases pose particular problems for jails, and screening for and treatment of these communicable
Mental Disorders
69
diseases have a large potential to improve public health.
Mental health problems are exceedingly common in jail
Left untreated in jail, other inmates, corrections officers
settings. In fact, jails have become the de facto mental
and staff may be infected, spreading disease to families
health providers for many communities.77
and friends in the general community even while the
nation’s largest jails, such as those in Los Angeles and
infected inmate remains behind bars. Given the rapid
New York, operate the nation’s largest psychiatric
turnover of jail populations, inmates themselves may
inpatient hospitals.78
simply carry the contagion back to their home commu-
percent of men and 75 percent of women in jail exhibit
nities. Without screening and testing, these inmates may
symptoms of mental disorder.79
70
Many of the
A recent report noted that 63 In the most carefully
designed study of prevalence of mental illnesses among
do so unknowingly.
jail detainees, researchers found that 6.1 percent of males Self-reported rates of infectious diseases among jail
and 15.0 percent of females admitted to the Cook County
detainees and inmates are: 2.6 percent for hepatitis, 4
(Chicago, Ill.) jail had symptoms of acute and serious
percent for tuberculosis (lifetime), 1.3 percent for HIV and
mental
0.9 percent for sexually transmitted diseases (STDs).71
disorder and major (unipolar) depression.80, 81 For lifetime
illnesses,
including
schizophrenia,
bipolar
These relatively low estimates based on self-report may
prevalence, these estimates increase to 8.9 percent for
be due to lack of awareness of the disease and
men and 18.5 percent for women. In addition, more than
low
50 percent of jail detainees have other mental health
access
to
health
care
in
the
community.
estimate
the
diagnoses, including dysthymia (8.3 percent), anxiety
prevalence of various diseases at higher levels.
For
disorders (10.8 percent) and antisocial personality
Other
studies
using
lab
screens
example, in Maryland jails, 6.6 percent of detainees and
disorders (44.9 percent).
inmates tested positive for HIV infection while prevalence
comparable rates of acute schizophrenia and bipolar
of hepatitis C was 29.7 percent and hepatitis B was 25.2
disorder (1.8 percent females vs. 3.0 percent males met
Veysey
Women and men had
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ISSUE PAPER criteria for schizophrenia; 2.2 percent females vs. 1.2 percent males for bipolar disorder). However, 13.7 percent
Interpersonal Violence, Community Disorder and its Consequences
of women met the criteria for depression compared In addition, a notable
Many chronic and infectious diseases are directly or
22.3 percent of women in jail met the criteria for
indirectly correlated with substance use, and appear to
to only 3.4 percent of men.
Clearly,
reflect common early negative childhood experiences. In
women in jail are more likely than their male counterparts
2002, 12 percent of jail detainees and inmates had lived in
to
a foster home or other institution at some time while they
post-traumatic exhibit
stress
disorder
symptoms
particularly
(PTSD).
of
depression
and
82
mental
illnesses,
post-trumatic
stress
were growing up, 46 percent had a family member who
disorder. Some have argued that the rate differential
had been incarcerated and a substantial proportion had
in
be
a parent or guardian who abused alcohol or other drugs
explained largely by differences in rates of exposure to
(20 percent alcohol, 2 percent drugs and 9 percent both
interpersonal violence across the lifespan (see discussion
alcohol and drugs).89 In addition, persons in jail are more
psychiatric
83
below).
diagnosis
by
sex
may
This same argument applies to sex differences
likely than the general population to have experienced
in drug abuse and dependence.
early childhood physical and/or sexual abuse. Fifteen
Co-occurring Substance Use and Abuse
vs. 45 percent of women) and 8 percent had been
Approximately 85 percent of the nation’s jail detainees
sexually abused before age 18 (4 percent of men and 36
were substance-involved in 2006 (up from 73 percent
percent of women).90 In nearly every case, the victim
in 1996). Alcohol plays a role in more than half and illicit
knew the abuser (92 percent).91
percent had been physically abused (11 percent of men
drugs in more than three-quarters of incarcerations.84 In the 2003 Arrestee Drug Abuse Monitoring (ADAM)
A decade-long, community-based investigation of over
Program report, 67 percent to 68 percent of arrested
17,000 respondents, the Adverse Childhood Events (ACE)
85
men and women tested positive for one or more drugs.
Study (see results discussed below), is arguably the
The most common drugs for both men and women
most important study investigating the relationship of
were cocaine and marijuana. According to the ADAM
negative childhood events to adult health. This study
data and based on a standardized screen of past-year
found that childhood traumatic events, particularly abuse
behavior, approximately one-quarter of arrestees are
and neglect, are associated with many adolescent and
at risk for alcohol dependence86
adult emotional, health and behavioral health problems.
23.8
percent
women)
(28.6 percent men vs. percent
The health consequences include obesity, STDs, liver
for dependence on other drugs (same rate for men
and
40.5
disease, ischemic heart disease and chronic obstructive
87
and women).
pulmonary disease. Adverse childhood events are related to poor mental health in general,92
Teplin
and
colleagues
also
found
that
a
large
depression
94
and suicide attempts.
hallucinations,93 95
They are also
percentage of admissions to jail had a diagnosable
related to alcohol use in general as well as age of first
substance
use,96 illicit drug use,97 adolescent pregnancy and fetal
use
disorder,
including
70.2
percent
of women (32.3 percent alcohol abuse/dependence
death98 and sexual risk behaviors.99
and 63.5 percent other drug abuse/dependence) and 61.3 percent of men (51.1 percent alcohol abuse/
The ACE study findings suggest that early childhood
dependence and 32.4 percent other drug abuse/
trauma leads to impaired neurodevelopment, adoption of
dependence).
risk behaviors in adolescence (such as smoking and other
These rates are even higher for
persons with a diagnosed mental illness. Among jail
substance use and unprotected sex), development of
detainees with serious mental illnesses, 74.9 percent of
chronic health problems in adulthood and early death. As
women and 72.0 percent of men have a co-occurring
the number of adverse childhood events increase, the
substance use disorder.88
odds of displaying specific problems in a number of
Veysey
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ISSUE PAPER domains, including mental health, addiction, sexuality, 100
risk behaviors and health, also increase.
Compared to
hospitalizations are very expensive.102, 103
For example,
according to one small jail administrator, a bypass
persons without negative childhood events, the odds
surgery may cost $75,000 to $100,000. This one fee “could
of any given problem typically increase by a factor of
take up about 15 percent of the jail’s total budget.”104
two to 10 times when four or more adverse childhood
Although small jails may unintentionally defer costs
events are present.101
through pre-trial release, the intentional release of a detainee to avoid the cost of medical care is not legally
As a conceptual organizing paradigm, the common
defensible. State and federal courts have ruled against
experience of adverse childhood events helps to
counties in these circumstances.105 Further, public safety
explain the complex and interrelated health, psychiatric
should not be sacrificed to economics when determining
and substance abuse problems that jail detainees and
who should be released pre-trial.106 However, carefully
inmates exhibit.
planned pre-trial release for the purpose of maintaining
Organization of Jail Health Care Services
increasing
non-violent individuals in their home communities, treatment
engagement
and
improving
continuity of care, can have direct effects on patient Jails provide health and psychiatric services to detainees
health and well-being and reduce municipal and county
and inmates in several ways. Breadth of services, organ-
correctional expenditures. In fact, this is the foundation
ization and staffing vary widely among U.S. jails and
upon which specialty courts are built. Mental health and
differ systematically by jail size. Large jails (over 1,000
drug courts divert arrestees from jail into community-
rated capacity) operate much more like prisons. They
based treatment services, maintaining individuals in their
often have a comprehensive array of services, including
home communities and often paying for treatment
medical/surgical units and an inpatient capacity. They
through Medicaid.
may have specialized housing units for persons with mental health problems as well as therapeutic communities.
Medical and psychiatric services may be provided directly
Because these very large jails also tend to employ their
by the jail, employing treatment staff and purchasing lab
own health care staff and directly administer health care
services, pharmaceuticals and other medical supplies.
services, linkages to community providers are weak and
Increasingly, however, moderate-size to large jails contract
non-violent indigent detainees are likely to be held
with for-profit correctional health care providers for all
pre-trial. The smallest jails rely almost exclusively on the
essential services.107 This is essentially a capitated cost
communities in which they are imbedded for medical and
system. The contractor agrees to provide specified services,
psychiatric care. Providers of care to jail detainees and
often including staff, lab services, medical and psychiatric
inmates are likely to be the same providers to these same
(and sometimes dental and optometry) treatment and
individuals after release. While small jails typically do
pharmacy services. As more service units are provided
not provide discharge planning, community ties to
or more resources are spent on expensive treatment
health providers are strong, creating an opportunity
alternatives, the contractor’s profit margin is reduced.
for continuous care.
Because of the nature of small
Contracted services by their very nature build in
communities and the relatively limited jail resources
disincentives for the health care organization to provide
(across the board from budget to security to treatment),
comprehensive, state-of-the-art treatment.108 For example,
non-violent individuals are likely to be released pre-trial.
South Carolina found that health care (medical and
When detainees are released pre-trial, the burden of
psychiatric) delivered by a privatized, for-profit provider
payment for treatment falls to the individual and not the
was of poor quality and involved cost overruns and
county. If a detainee remains behind bars and needs
expenditures on services that were never provided.109
critical care, small jails will transport the individual to a local emergency room or hospital. In this case, the cost
Finally, a model of community-oriented correctional
of care remains with the jail.
health care is emerging that partners jails with community
Veysey
In many cases, these
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ISSUE PAPER providers and can be implemented by even large jails.
cost-shifting means the shifting of costs from one
Based upon principles of public health, the Hampden
organization or governmental entity to another for the
County Correctional Center (population approximately
same service or treatment.
1,800) contracts with local community health centers
restrictions on Medicaid eligibility would shift costs from
For example, increased
“that provide care and case management both on-site
federal and state dollars onto those providers that treat
at the jail and after release.”110 Approximately 80 percent
indigent individuals (such as federally qualified health
of the population comes from a single urban center
centers) that bear most of the costs themselves. Domino
that is also served by these facilities. Dually locating
and colleagues suggest that community providers
health care staff creates relationships between the
or managed care organizations shift costs to local jails
patient and provider that increase the likelihood that the
indirectly. By failing to provide adequate care, these
patients will pursue their treatment plans after release.
organizations
This arrangement also avoids common information
conditions (and arguably those with addictive disorders)
exchange barriers, increases the breadth and quality
at increased risk of arrest and jail confinement. In fact,
of services and provides financial incentives to provide
given the comorbidity of chronic and infectious disease
111, 112
quality care.
place
persons
with
mental
health
with mental and substance use disorders, failure in one area increases general health care costs as well as public
Financing of Jail Health Care Services
health risks.
Historical changes in law and policy have led to the
Obviously,
decrease of affordable treatment in the community and
from one setting to another.
an increased reliance on jails and prisons to manage an
organizational decisions that have a profound and long-
increasingly ill population. The deinstitutionalization of
term effect on patients’ lives.
persons with mental illnesses in the 1970s and 1980s,
treatment of indigent people from one type of govern-
new drug laws and the concomitant reductions in federal
ment funding support to another is a failure. There is
cost-shifting
requires
moving
patients
These are policy and In this case, shifting
support for substance abuse treatment, increased
no evidence to suggest that people receive better care
eligibility restrictions on Medicaid and Medicare receipt
in jail. At the same time, confinement in jail disrupts
and
lives and families.
even
the
expansion
of
health
management
organizations and mental health/substance abuse carveouts have contributed to the reduction in community-
To a large degree, counties and municipalities bear the
based health care resources.113
costs of jail health care.
Many of these policy changes had the effect of shifting
budget item,116 and health care accounts for about 15
In many municipalities and
counties, correctional services are the fastest-growing costs. For example, some argue that the deinstitutional-
percent of jails’ budgets (excluding costs of mental
ization of individuals with mental illnesses from long-term
health services and hospitalizations).117 In real terms, for
inpatient psychiatric hospitals led to many being
example, this amounts to $24 million a year in the Miami-
arrested and sent to jails and prisons because of the lack
Dade area118
of comprehensive psychiatric services and supported
77,000 individuals a year.119)
housing in their communities.
114
This shifted the costs
(Broward County books approximately These costs are incurred
partially because of suspension of health insurance
from state mental health budgets, where services were
payments,
often reimbursable through federal dollars, to state and
Medicaid and Medicare, upon confinement, and partially
local correctional budgets.
due to lack of any insurance coverage for a large
particularly
federal
benefits
such
as
proportion of the arrestee population. While there is Cost-shifting in the health care literature often refers to
no federal requirement to terminate federal benefits,120, 121
“raising private reimbursement rates in response to lower
most jurisdictions and local Social Security offices have
public reimbursement rates.”115 In the current context,
standing policies to do so.122
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ISSUE PAPER Three facts are worth mentioning in regard to the practice
internal resources. The many U.S. jails that fall in the mid-
of Medicaid termination.
First, access to community
range population are neither large enough to financially
health care for Medicaid recipients is similar to that for
support full-time medical and psychiatric staff and
the privately insured population and much greater than
lab and pharmacy services nor small enough to make
123
Second, not only can maintenance
maximum use of community resources. For these mid-
of Medicaid benefits result in greater access to care, but
size jails, the most common solution to skyrocketing
that for the uninsured.
“it can also (1) reduce the financial burden on state and
health costs and high-risk patient populations is to
local governments that fund indigent health care systems
contract with privatized for-profit correctional health
and (2) increase the number of disabled who receive treatment.”124
offenders
care providers. Clearly, the advantage of this strategy
Third, in one study of two
is that the county can anticipate the contract costs.
large jails, 97 percent of offenders who were receiving
However, there are also substantial potential downsides
Medicaid benefits at booking were not incarcerated long
to these contracts, including poor quality of care, lack of
enough to have their benefits terminated.125 Taken together,
capacity for information exchange and little incentive for
these facts suggest that patient engagement and conti-
release planning or follow-up.
nuity of care may be enhanced while reducing county costs simply by not terminating benefits immediately.
Potential Leveraging of Health Care Reform
Further, if the ACA exception for detainees is supported, The implications of the ACA for jail-based health care
termination of benefits may no longer be allowed.
may be profound.130 The legislation will have at a minimum Some states have implemented or are considering
an indirect impact on all detainees and inmates,
legislation that would require individuals who have
unsentenced and sentenced. It may also have a direct
private insurance to pay for any medical care they receive
impact for those awaiting trial or sentencing if the ACA
while in jail (see, for example, Florida and Utah). This
allows third-party reimbursement.
strategy has met with strong resistance by the insurance
Medicaid expansion and the creation of insurance
industry, but with support from legislators and the general
exchange coverage will vastly increase the number of
Most importantly,
Other jurisdictions are investigating the option
people covered by health insurance who, at present,
of covering jail inmate populations through competitive
either do not receive any treatment at all or use
126
public.
health insurance plans similar to those used by small 127
businesses.
Both options, however, make it difficult for
emergency
rooms
as
their
provider
of
choice.
Although health behaviors are not expected to change immediately, over time the poorest of the American public
insurers to assess the patient risk profile.
are predicted to act like their more privileged counterSeveral states are considering legislation limiting the
parts in their medical decisions, including preventive care
reimbursement rates that outside providers can charge
and regular treatment for chronic health problems.
jails for services. For example, Colorado passed a bill (SB 03-141) that requires that any health care provider
The ACA is also likely to affect many aspects of the health
receiving state funding charge the county the same
care delivery system, including parity for mental and
reimbursement rate as it charges Medicaid. This reduces
substance use disorders, the broad use of electronic
the reimbursement rate from 75 percent or more to about
medical records and increased access to pharmaceuticals.
and shifts costs from the county
In addition, the law emphasizes the importance of
budget to the hospital or community provider. In some
developing community-based “medical homes.” All these
cases, providers are walking away and refusing jail
ancillary aspects of health care reform — expanded
35 percent of cost
128
129
patients and the attendant lower reimbursement rate.
coverage, integrated behavioral health and primary health care, comprehensive information transfer and medication
Many small and very large jails have found ways to meet
accessibility — could have a large effect on continuity of
their health care challenges through creative use of
care from pre-arrest through jail and re-entry, while
Veysey
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ISSUE PAPER reducing recidivism and increasing overall public safety.
cases, these individuals present no greater risk to the community than those who are released either through
The single largest and predictable outcome that the ACA
bail or on their own recognizance.
may have on corrections is in addiction treatment. Early intervention, together with an array of treatment
However, in order for these programs to succeed and
resources, including inpatient, residential, outpatient and
for judges to release individuals to the community, a
medication-assisted support, means more people in the
sufficient array of services is needed, and Medicaid agencies
community in recovery with longer periods of abstinence.
must be encouraged to establish policies that will
This in turn may translate to fewer drug-related crimes or
increase service availability and expand the breadth of
crimes committed for the purpose of purchasing drugs
services that are reimbursable. This is particularly true for
and fewer negative health consequences, particularly
persons with alcohol and other drug addictions. Since
infectious diseases such as HIV, hepatitis and STDs and
individuals cycling through jails are community patients
chronic conditions such as heart disease and chronic
as well, keeping these individuals in their communities
pulmonary obstructive disorder.
carries enormous health benefits while not increasing, and potentially decreasing, community (i.e., taxpayer)
In general, improving the health of all Americans will lead
health care costs.
to improved health of jail detainees and inmates. With the potential shift in focus for poor Americans from
Finally, if indeed detainee health care coverage is allowable,
emergency care to prevention and early intervention,
there are important consequences for jail health care
theoretically those who are arrested will arrive at jail in
staffing and standards of care. In the future, jails and/or
better health. Further, if health insurance under the ACA
contract providers will be required to hire physicians and
allows for federal reimbursement of health care services
other health care staff who meet the highest standards
for detainees, community health care providers will
of community treatment to be compliant with Medicaid
have financial incentives to continue to treat this group.
requirements. Further, Medicaid requires specific outcome
In this case, jails may be more likely to contract with
measures. This means that the facility must actually meet
community providers rather than large, national for-profit
these standards and have an information system that can
correctional health care organizations.
track these outcomes.
Even in the absence of reimbursement for detainee
Jails
health care, jails may be interested in exploring ways
opportunities as the nation prepares for full implementation
of shifting costs from county budgets onto state and
of the ACA. They now have incentives to become critical
federal governments through the development and
public health outposts for identifying and treating people
implementation of community-based release programs
with serious health needs.
(including formal diversion programs, other structured
integrated community-based agencies working with
face
incredible
challenges
and
incredible
They can become truly
alternatives to incarceration and release on recognizance)
other health care agencies to ensure continuous, uninter-
for
and/or
rupted care. This public health vision of correctional
substance-related charges. As noted, persons without
health care shows promise for improving the public’s
financial resources often cannot make bail and therefore
health and safety while incurring less cost to local
remain in jail while awaiting trial and sentencing. In many
governments and to taxpayers.
indigent
Veysey
individuals
with
non-violent
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ISSUE PAPER References The Corrections and Re-entry Policy Research Center grew out of the former Center for Justice and Mental Health Research. The former Center was founded in 1998 to investigate issues related to behavioral health populations and services in U.S. correctional settings. The goal of the Center was to partner research and practice across multiple disciplines to identify critical needs and points of intervention, and to test treatment effectiveness of services. 2 Kleycamp M, Rosenfeld J and Scotti R. Wasting Money, Wasting Lives. Trenton, NJ: Drug Policy Alliance, 2008. 3 Reentry: A Strategy for Safe Streets and Neighborhoods. Trenton, NJ: The State of New Jersey, 2007. 4 One in 100: Behind Bars in America 2008. Washington, DC: The Pew Charitable Trusts, 2008. 5 Minton TD. “Jail Inmates at Midyear 2009-Statistical Tables.” Bureau of Justice Statistics Statistical Tables (NCJ 230122). Washington: U.S. Department of Justice, 2010. 1
6
ibid. James DJ. “Profile of Jail Inmates, 2002.” Bureau of Justice Statistics Special Report (NCJ 201932). Washington: U.S. Department of Justice, 2004. 8 Conklin TJ, Lincoln T and Wilson R. A Public Health Manual for Correctional Health Care. Ludlow, MA: Hampden County Sheriff’s Department, 2002. 9 The Health Status of Soon-to-be-Released Inmates. A Report to Congress. Volume 1. Chicago: National Commission on Correctional Healthcare, 2002. 10 Cohen F and Dvoskin J. “Inmates with Mental Disorders: A Guide to Law and Practice.” Mental and Physical Disability Law Reporter, 16: 339-346, 462-470, 1992. 11 Morris SM, Steadman HJ and Veysey BM. “Mental Health Services in United States Jails.” Criminal Justice and Behavior, 24(1): 3-19, 1997. 12 Torrey EF, Stieber J, Ezekiel J, et al. Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals. Washington: Public Citizen’s Health Research Group and the National Alliance for the Mentally Ill, 1992. 13 Domino ME, Norton EC, Morrissey JP and Thakur N. “Cost Shifting to Jails after a Change to Managed Mental Health Care.” Health Services Research, 39(5):1379-1401, 2004, p. 1380. 14 Several specific groups will remain ineligible for coverage under the ACA, including convicted jail and prison inmates and military personnel (and undocumented persons who are not, by definition, U.S. citizens). 15 Blair P, Greifinger T and Stone TH. “Eligibility of Pre-trial Detainees under the Patient Protection and Affordable Care Act.” Unpublished paper, 2010. 16 Conklin, Lincoln and Wilson, p. ix. 17 ibid. 18 ibid. 19 Sabol WJ and Minton TD. “Jail Inmates at Midyear 2007.” Bureau of Justice Statistics Bulletin (NCJ 221945). Washington: 7
Veysey
U.S. Department of Justice, 2008. 20 Minton. 21 Camp CG and Camp GM. The 2000 Corrections Yearbook: Jails. Middletown, CT: Criminal Justice Institute, 2000. 22 ibid. 23 ibid. 24 Beck AJ. “The Importance of Successful Reentry to Jail Population Growth.” (Presentation to The Urban Institute Jail Reentry Roundtable, Washington, DC, June 27, 2006.) 25 ibid. 26 Minton. 27 ibid. 28 This estimate is based upon the 478,100 admissions to state and federal prisons for a new court commitment (i.e., not a parole violation) in 2008, as reported in Sabol WJ, West HC and Cooper M. “Prisoners in 2008.” Bureau of Justice Statistics Bulletin (NCJ 228417). Washington: US Department of Justice, 2009. This estimate is divided by 12.8 million jail admissions in the same year (Beck, 2006) resulting in 3.7 percent. 29 U.S. Department of Justice, Federal Bureau of Investigation. Crime in the United States, 2009, Preliminary Annual Uniform Crime Report, www.fbi.gov/ucr/prelimsem2009/index.html (accessed September 2010). 30 James. 31 Solomon AL, Osborne JWL, LoBuglio SF, et al. Life After Lockup: Improving Reentry from Jail to the Community. Washington, DC: Urban Institute Justice Policy Center, 2008. 32 Thanks to Pamela Rodriguez, Arthur Lurigio, Melody Heaps, Maureen McDonnell, Laura Brookes and Seth Eisenberg at the Center for Health & Justice at TASC for information contained in this paragraph. 33 Minton. 34 Sabol and Minton. 35 Cohen and Dvoskin. 36 Moore J. “Public Health Behind Bars.” Popular Government, Fall: 16-23, 2005. 37 Estelle versus Gamble, 429 U.S. 97, 1976. 38 Bowring versus Godwin, 551 F.2d. 44, 47 (4th Cir.), 1977. 39 N.B., substance abuse treatment is not generally considered to fall under this mandate except for medical detox. 40 Minton. 41 James. 42 U.S. Department of Justice, Federal Bureau of Investigation. Crime in the United States, 2008, Table 41, www.fbi.gov/ ucr/cius2008/data/table_41.html (accessed August 2010). 43 Harlow CW. “Education and Correctional Populations.” Bureau of Justice Statistics Special Report (NCJ 195670). Washington: U.S. Department of Justice, 2003. 44 ibid. 45 James. 46 N.b., these are 2002 estimates and do not reflect the current economic situation. 47 James.
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ISSUE PAPER 48
Individuals report all sources of income. Therefore, these estimates reflect duplicated counts. 49 Wang EA, White MC, Jamison R, Goldenson J, Estes M and Tulsky JP. “Discharge Planning and Continuity of Health Care: Findings From the San Francisco County Jail.” American Journal of Public Health, 98 (12): 2182-84, 2008. 50 Conklin, Lincoln and Wilson. 51 ibid. 52 Wang, White, Jamison et al. 53 Conklin TJ, Lincoln T and Tuthill RW. “Self-Reported Health and Prior Health Behaviors of Newly Admitted Correctional Inmates.” American Journal of Public Health, 90:1939-1941, 2000. 54 Minton. 55 James. 56 Conklin, Lincoln and Wilson. 57 See, for example, Artinian MP, Templin TN, Stallwood LG and Hermann CE. “Functional Health Literacy in an Urban Primary Care Clinic.” The Internet Journal of Advanced Nursing Practice, 5(2), 2003.
2007. 70 Williams NH. “Prison Health and the Health of the Public: Ties That Bind.” Journal of Correctional Health Care, 13(2):80-92, 2007. 71 ibid. 72 Solomon L, Flynn C, Muck K and Vertefeuille J. “Prevalence of HIV, Syphillis, Hepatitis B, and Hepatitis C Among Entrants to Maryland Correctional Facilities.” Journal of Urban Health, 81(1):25-37, 2004. 73 White MC, Tulsky JP, Goldenson J, et al. “Randomized Controlled Trial of Interventions to Improve Follow-up for Latent Tuberculosis Infection After Release From Jail.” Archives of Internal Medicine, 162:1044-1050, 2002. 74 Mertz KJ, Schwebke JR, Gaydos CA, et al. “Screening Women in Jails for Chlamydial and Gonococcal Infection Using Urine Tests: Feasibility, Acceptability, Prevalence, and Treatment Rates.” Sexually Transmitted Diseases, 271-276, 2002. 75 Conklin, Lincoln and Wilson.
58
77
Gazmararian JA, Baker DW, Williams MV, et al. “Health Literacy Among Medicare Enrollees in a Managed Care Organization.” Journal of the American Medical Association, 281(6):545-551, 1999. 59 Ashton CM, Haidet P, Paterniti DA, et al. “Racial and Ethnic Disparities in the Use of Health Services: Bias, Preference, or Poor Communication.” Journal of General Internal Medicine, 18(2): 146-152, 2003. 60 Poverty in America: Economic Research Shows Adverse Impacts on Health Status and Other Social Conditions as well as the Economic Growth Factor. Washington: U.S. Government Accountability Office, 2007. 61 Lindquist CH and Lindquist CA. “Health Behind Bars: Utilization and Evaluation of Medical Care Among Jail Inmates.” Journal of Community Health, 24(4): 285-303, 1999. 62 Keppel KG, Pearcy JN and Wagener DK. Trends in Racial and Ethnic-specific Rates for Health Indicators: United States, 19901998. Centers for Disease Control, National Center for Health Statistics. Atlanta: U.S. Department of Health and Human Services, 2002. 63 Conklin, Lincoln and Wilson. 64 Maruschak LM. “Medical Problems of Jail Inmates.” Bureau of Justice Statistics Special Report (NCJ 210696). Washington: U.S. Department of Justice, 2006. 65 ibid. 66 ibid. 67 Bell JF, Zimmerman FJ, Cawthorn ML, Huebner CE, et al. “Jail Incarceration and Birth Outcomes.” Journal of Urban Health, 81:630–644, 2004. 68 Maruschak, 2006. 69 Lincoln T, Miles JR and Scheibel S. “Community Health and Public Health Collaborations.” In Public Health Behind Bars: From Prisons to Communities, Greifinger R (ed.). New York: Springer,
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The Health Status of Soon-to-be-Released Inmates. Torrey EF. “Jails and Prisons: America’s New Mental Hospitals.” American Journal of Public Health, 85(1):1611-13, 1995. 78 Freudenberg N. “Jails, Prisons, and the Health of Urban Populations: A Review of the Impact of the Correctional System on Community Health.” Journal of Urban Health, 78(2): 214-235, 2001. 79 James DJ and Glaze LE. “Mental Health Problems of Prison and Jail Inmates.” Bureau of Justice Statistics Special Report (NCJ 213600). Washington: US Department of Justice, 2006. 80 Teplin LA. “Psychiatric and Substance Abuse Disorders Among Male Urban Jail Detainees.” American Journal of Public Health, 84(2): 290–293, 1994. 81 Teplin LA, Abram KM and McClelland GM. “Prevalence of Psychiatric Disorders among Incarcerated Women.” Archives of General Psychiatry, 53:505–512, 1996. 82 ibid. 83 See, for example, Veysey BM. “Mental Health Issues of Incarcerated Women,” in Levin BL and Becker MA (eds.). A Public Health Perspective of Women’s Mental Health. New York: Springer, 2010. 84 Behind Bars II: Substance Abuse and America’s Prison Population. New York: The National Center on Addiction and Substance Abuse at Columbia University, 2010. (No authors given.) 85 Zhang Z. Drug and Alcohol Use and Related Matters Among Arrestees 2003. Washington: U.S. Department of Justice, 2004. 86 “Risk of dependence to alcohol” in the ADAM assessment is defined as “an indication of need for treatment, … measured by a clinically based dependency screen regarding alcohol use experiences during the prior year.” Zhang. 87 Zhang. 88 Teplin, Abram and McClelland. 89 James. 90 Other studies using different methodologies report much
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ISSUE PAPER higher abuse rates, particularly for females. For greater detail, see Veysey, 2010. 91 James. 92 Edwards VJ, Holden GW, Anda RF and Felitti VJ. “Relationship between Multiple Forms of Childhood Maltreatment and Adult Mental Health: Results from the Adverse Childhood Experiences Study.” American Journal of Psychiatry, 160:1453–1460, 2003. 93 Whitfield CL, Dube SR, Felitti VJ and Anda RF. “Adverse Childhood Experiences and Hallucinations.” Child Abuse and Neglect, 29:797–810, 2005. 94 Chapman DP, Whitfield CL, Felitti VJ, et al. “Adverse Childhood Experiences and the Risk of Depressive Disorders in Adulthood.” Journal of Affective Disorders, 82:217–225, 2004. 95 Dube SR, Anda RF, Felitti VJ, et al. “Childhood Abuse, Household Dysfunction and the Risk of Attempted Suicide Throughout the Lifespan: Findings from Adverse Childhood Experiences Study.” Journal of the American Medical Association, 286:3089–3096, 2001.
Strategies for Criminal Offenders.” Journal of Health Care Finance, 26(1):63-77, 1999. 108 ibid. 109 Rosenthal MG. “Prescription for Disaster: Commercializing Prison Health Care in South Carolina.” Special Report. Charlotte, NC: Grassroots Leadership South Carolina Fair Share, 2004. 110 Conklin, Lincoln and Wilson, p.30. 111 While Medicaid reimbursement for services is suspended during the jail stay, the individual is not disenrolled. Further, preventive care and improved health behaviors reduce the use of urgent and emergency care. Finally, this arrangement reduces the use of indigent care after release. See Conklin, Lincoln and Wilson. 112 Conklin, Lincoln and Wilson. 113 Pollack, Khoshnood and Altice. 114 See, for example, Veysey BM and Steadman HJ. Double Jeopardy: Persons with Mental Illnesses in the Criminal Justice System. Report to Congress. Washington, DC: Center for Mental Health Services, 1995.
96 Dube SR, Miller JW, Brown DW, et al. “Adverse Childhood Experiences and the Association with Ever Using Alcohol and Initiating Alcohol Use during Adolescence.” Journal of Adolescent Health, 38:444.e1–444.e10, 2006. 97 Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH and Anda RF. “Childhood Abuse, Neglect and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experience Study.” Pediatrics, 111:564–572, 2003. 98 Hillis SD, Anda RF, Dube SR, et al. “The Association Between Adolescent Pregnancy, Long-Term Psychosocial Outcomes, and Fetal Death.” Pediatrics, 113:320–327, 2004. 99 Hillis SD, Anda RF, Felitti VJ and Marchbanks PA. “Adverse Childhood Experiences and Sexual Risk Behaviors in Women: A Retrospective Cohort Study.” Family Planning Perspectives, 33:206–211, 2001. 100 Anda RF, Felitti VJ, Bremner JD, et al. “The Enduring Effects of Abuse and Related Adverse Experiences in Childhood: A Convergence of Evidence from Neurobiology and Epidemiology.” European Archives of Psychiatry and Clinical Neuroscience, 256:174–186, 2006. 101 ibid. 102 Lundby T. “Medical Expenses Remedied: Boone County Jail Has a New Protocol for Medical Treatments.” The Missourian, August 14, 2005, www.columbiamissourian.com/stories/ 2005/08/14/medical-expenses-remedied/ (accessed September 2010). 103 Shimkus J. “Community Provider Fees Too Steep? There Oughta Be a Law!” CorrectCare, Fall, 2003. 104 Bennett L. “Jail Inmates Get Health Insurance.” WCTV.tv, February 4, 2010. www.wctv.tv/home/headlines/ 83594802.html (accessed September 2010). 105 Moore. 106 ibid. 107 Pollack H, Khoshnood, K and Altice F. “Health Care Delivery
115
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Domino, Norton, Morrisey and Thacker, p. 1380. Freudenberg. 117 Based upon a 1999 NCCHC/NIC study of 17 of the 30 largest U.S. jails as cited in Lincoln et al., 2007. 118 Dorschner J. “Prisoners’ Health Bills in Spotlight for Jackson Health System.” The Miami Herald. September 20, 2010. 119 Broward Sheriff’s Office. www.sheriff.org/about_bso/dodcc/ (accessed September, 2010). 120 Griffin PA, Naples M, Sherman RK, et al. Maintaining Medicaid Benefits for Jail Detainees with Co-Occurring Mental Health and Substance Use Disorders. Delmar, NY: The National GAINS Center for People with Co-Occurring Disorders in the Justice System, 2002. 121 Perez LM, Ro MJ and Treadwell HM. “Vulnerable Populations, Prison, and Federal and State Medicaid Policies: Avoiding the Loss of a Right to Care.” Journal of Correctional Health Care, 15(2):142-149, 2009. 122 Lipton L. “Medicaid Eligibility Termination Plagues Former Inmates.” Psychiatric News, 36(17): 8, 2001. 123 Morrissey JP, Steadman HJ, Dalton KM, et al. “Medicaid Enrollment and Mental Health Service Use Following Release of Jail Detainees With Severe Mental Illness.” Psychiatric Services, 57(6):809-815, 2006. 124 Moses M and Potter RH. “Obtaining Federal Benefits for Disabled Offenders. Part 1 - Social Security Benefits.” Corrections Today, April: 112-114, 2007, p.112. 125 Moses M and Potter RH. “Obtaining Federal Benefits for Disabled Offenders. Part 2 - Medicaid Benefits.” Corrections Today, June: 76,78, 2007. 126 Shimkus. 127 Bennett. 128 Shimkus. 129 ibid. 130 Blair, Greifinger and Stone. 116
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